TO: American Academy of Healthcare Providers in
the Addictive Disorders

FROM: Wes James Orr, M.S.W., LMSW, ACSW, CAS

20 March 2012

Noble Warriors turning to drink and drugs: The high costs of the isolation of gay and bisexual
soldiers returning from tours of duty (a call to research).

Abstract

This is a call to study
the insufficiently researched topic of lesbian, gay and bisexual (LGB) active
duty personnel in the military who have recently returned from a stressful deployment
often returning to a home in a foreign land prior to returning to the United
States. It is clear in the research that
individuals experiencing stressful deployments are at a higher risk for alcohol
and drug addiction, mental health difficulties and other problems upon their
return. What is not known, since the
literature is largely silent on this issue, is the question of how lesbian, gay
and bisexual soldiers cope with such experiences and whether risks of substance
abuse and addiction, including co-occurring disorders, are equally as high for
this group as other soldiers. The author
hypothesizes that LGB soldiers are less inclined to link into support services due
to potential social isolation and stigma. A further hypothesis is that this group is not utilizing existing
medical supports due to confidentiality and other concerns. The author argues that if these hypotheses
were to be confirmed and proactively addressed by the military, LGB soldiers
would link in more with services and this would promote recovery and enhance
productivity and job retention.

Research
Rationale

It is a known fact that military personnel who deploy to war zones
are at risk of developing or risk exacerbating existing problems with Alcohol,
Tobacco or Other Drugs (ATOD) or other co-occurring disorders.17 In
persons who identify as being lesbian, gay or bisexual (LGB) these risks of
substance abuse, addiction and other co-occurring mental health difficulties
are likely as high as others in similar circumstances.The difference, however, is in how to
properly screen LGB individuals in order to link them into relevant treatment
providers and services that will meet their specific needs and maximize
positive treatment outcomes. This
distinction is important, in part, due to the stigma and confidentiality issues
already attached to going for help when developing signs of alcohol, other drug
problems or mental health difficulty. When this is combined with being part of a(n), often, disfavored
minority group (as persons who identify as LGB are) the available supports and
the typical social outlets often present for their heterosexual peers are
either under-utilized or avoided altogether.19 This call to research aims to show that the
lack of familiarity, in particular, to the specific needs of the LGB soldier by
treatment providers and community services will likely result in fewer
self-referrals and treatment outcomes will likely not be maximally
effective. This combined with reduced
social connections in isolated LGB soldiers can plausibly drive an increased
reliance upon alcohol and/or other drugs (ATOD) as a means to cope. Implications include not linking into
available prevention and treatment programs from an early stage due to
perceived confidentiality concerns or that the LGB soldier believes that they
will be judged or that their individual circumstances will not be
understood. Further, potential
consequences include the development and progression of treatment resistant
alcohol or chemical dependency and related behavior problems potentially
disrupting one's unit and the individual soldier's job performance. Serious
lapses in judgment or behavioral difficulties as a result of substance use
disorders can pave the way to expensive disciplinary proceedings leading to a
dishonorable discharge from the military. All of these scenarios would be very costly to both the individual, his
or her unit morale and, ultimately, to the greater military community who has
likely invested tens of thousands of dollars worth of training into each and
every individual soldier (see Enforcing
DADT cost $52,800 per troop). 5

Introduction

Every year
American soldiers return from active deployments often in countries where the
U.S. is in a state of war or fighting terrorism (recent examples include both
Iraq and Afghanistan). Many times these
soldiers have been in very stressful environments where extreme circumstances
were present. 4, 9 Examples of these situations include individuals
being in the immediate or close vicinity of combat areas or directly observing
fellow soldiers in one's own unit or battalion suffering debilitating or disabling
injuries or dying. Further, in war
zones, there is always the imminent and possible daily threat of coming into
contact with improvised explosive devices (IEDs) or being killed or captured
and tortured. As will be demonstrated
below there is a high correlation of soldiers being in these environments and
experiencing traumatic stress and turning to substance abuse and having other
co-occurring mental health difficulties (e.g. PTSD, Anxiety or
Depression). It is the author's
contention that gay, lesbian and bisexual (LGB) service members experience the
same difficulties but potentially receive fewer services particularly when they
are not open about their sexuality.19

This modest
subset of individuals (likely 5% or higher) 8 have their problems
compounded by societal or institutional homophobia and rejection. Depending on one's own inferences and beliefs
this rejection can often become internalized, turning into unhealthy, morale killing,
shame or depression. By not believing
they can be open about their identity, aspirations and goals-including choice
of partner, already difficult emotions are exacerbated leading to internalized
homophobia. Further, combining this
shame with a reluctance to link in to available services when exhibiting signs
and symptoms of AOD problems or co-occurring disorders (this reluctance to link
or disclose problems are common amongst all service members with AOD problems),
18 and experiencing relative social isolation are (this author believes)
huge additional risk factors that require specialized knowledge, skills and
non-judgmental attitudes of the military service provider.

Literature Citation

Some years ago Hoge et al. reported in a study of returning Iraq soldiers
a high incidence of mental health problems (nearly 20% who returned from Iraq).
1 Further research has
demonstrated a high incidence of PTSD and the link between PTSD and substance
abuse. 9 My focus in this call to research is, specifically, on
soldiers who self-identify as being of a gay, lesbian or bisexual (LGB)
orientation and who have recently returned from deployment in the above
mentioned circumstances. It is my
contention (needing confirmation) that soldiers in these circumstances are at
an increased risk of either not linking in to available medical and/or
community supports (non-military bisexuals in one study exhibited lower levels
of self-disclosure and community connection as compared with gays and
lesbians), 7 when needed, and/or are socially isolated and who would
be more likely to turn to drink or drugs in the absence of this much needed
community and social support.

An additional
problem, by gender, present primarily in women, by proportion, is the
prevalence of deployed women who experience sexual abuse and/or rape which was
found to be 7% (in referencing a 1995 DOD study and noting that these crimes
are often underreported by women who must continue to work with their
perpetrator).11 Also,
estimates vary, but when looking at career military sexual harassment the
estimate is much higher, anywhere from 34-78%, at the hands of their fellow
servicemen.13 This
disturbingly high proportion surely affects all women service members' experience.10
Additionally, it is another
traumatic event (compounding an otherwise already stressful deployment), that,
likely, further complicates and isolates, specifically, the female soldier who
also identifies as lesbian or bisexual.
When the above female soldier is not already linked into a supportive
social network (who might assist in recognizing problems or recommending the
need for treatment) and believes that she has nowhere to turn she would likely
choose to delay or avoid treatment especially if confidentiality concerns
exist. This is despite the fact that
women, generally, are more likely to
access and link into necessary medical services, 6 and seek out
social support and have broader social networks than men. Unfortunately women in these circumstances
would likely turn to drink or possibly drug (or prescription) abuse in the
absence of other supports as a means to cope.

Further problems
identified by gender are that men are less likely, generally, to access
preventative and acute medical care. 6 As noted earlier all persons
regardless of gender are less likely to link into needed supports when issues
of alcohol or drug abuse are present.
Men who identify privately as being gay or bisexual have additional risk
factors and even more reason to isolate from others or refuse to engage with
services. 14 In the author's view men are more severely judged by
other men in relation to sexual identity and perceived differences in
masculinity. Even at an early age boys
experiencing sexual harassment by their peers are very troubled by pejorative
references to being called "gay". 15 Men who experience
anti-gay harassment, discrimination and violence are shown to have a higher
association with problems of lowered self-esteem and report a significant
increase in reporting suicidal ideation. 14 Additionally, one study
showed that in men who have sex with men, low self-esteem and internalized
homophobia can impact on risk-taking behaviors. 16

Given the above
circumstances which are unique to the LGB soldier it is often, therefore,
easier to isolate oneself or at least keep ones sexual orientation a
secret. In fact, this secrecy,
regardless of gender, would be expected given the controversy surrounding even
the repeal of Don't Ask Don't Tell (DADT) which had been hotly debated for
years and only recently rescinded.
Previously even the hint of a relationship with a same-gendered partner
would bring up significant confidentiality concerns and the likelihood of
discharge from the service.2There is
debate both by current Presidential candidates and many in Congress to
reinstate DADT so even the status of this legislation continues to be in
question. This, understandably, is a
continuing concern of LGB persons, who either have already, or, who are
contemplating disclosing their orientation to treatment providers. Unfortunately, this secrecy around one's
sexual orientation (which can legitimately be seen as a means to protect ones
career), can and does lead to further isolation and not linking into or fully
utilizing (in terms of disclosing pertinent information), necessary services or
community supports which can otherwise mitigate against a serious AOD problem
from developing. In Frank's study (2004),
soldiers who are open about their sexuality "report greater success in bonding,
morale, professional advancement, levels of commitment and retention and access
to essential support services".19

Suggested Research Plan

As the author is
not, at this juncture, suggesting having the current means, or the funding, to
carry out the proposed research (although he would welcome the chance should
the opportunity arise), a detailed research plan and methods, and, obviously,
findings are not included. A statement
of relevant research questions and recommendations, however, are in order. It is believed that these would positively
guide persons having the ability to respond to and carry out the proposed
research.

-Policy Considerations

It was reported
recently in the USA Today online (14 March 2012) that the U.S. Army is discontinuing
plans for rolling out worldwide their pilot program of soldiers having their
confidentiality assured in terms of reported alcohol abuse. This discontinuation was reportedly done due
to the large number of treatment drop-outs.12The
author could not, at this time, find other, more detailed explanations for this
change and encourages the prospective research funding source(s) or reader
contemplating this research to consider the following:

Professionals
treating addiction are aware of the vital importance of client confidentiality.

Client
confidentiality with all persons, including LGB soldiers, must be ensured both
in terms of valid research findings but also to increase and prolong treatment
participation.

The
therapeutic alliance will be severely compromised should a client's confidences
be shared.

If
a client's confidential information is shared for reasons other than an imminent
threat to life of self or others or a child protection concern, future therapy
is compromised.

It
is necessary to look at and promote creative strategies to increase
self-referrals and to minimize treatment drop-outs.

The
Army was on the right track by offering confidential treatment options, which
are in line with international best practice standards.

Resuming
confidential counseling would demonstrate a commitment to soldiers wishing to
achieve recovery and will significantly aid in relapse prevention.

-Research Questions stated

Are
LBG soldiers returning from stressful deployments as likely to abuse substances
as their peers? If so, will they respond
as well to existing treatments?

Does
perceived social isolation or the lack of confidentiality factor into the
avoidance of early treatment or self-referral by LGB soldiers?

What
are the costs both to the individual and to the military of LGB soldiers
developing advanced substance use disorders that could be screened and treated earlier?

What
strategies can be employed to promote earlier treatment enrollments and to
encourage treatment longevity?

How
can the LGB soldier's positive and healthy social outlets be promoted?

-Further Suggestions as to time plan and sampling methods

The author wishes
to give a couple of brief suggestions as to a time plan and sampling
methods. One possible scenario would be
over a three to six month period to confidentially sample a statistically
representative portion of soldiers returning from deployment. Also, due to the fact that deployed female
soldiers are a smaller group it would be important to oversample this group to
have a representative data-set. This sampling could be achieved either through
confidential web-based surveys or surveys given to randomly selected groups of
soldiers who are being de-briefed after returning from stressful deployments.
One option to maximize accuracy in reporting, and to further reinforce
perceived confidentiality, is to disseminate the surveys at the end of the briefing
and with the commanding officers not present.
These could be collected by service personnel of a similar rank but not
affiliated with the company or unit in question. At the end of the six month
data collection period the information could be tabulated and decisions made to
possibly pilot treatment strategies that are confidential and aim to
demonstrate that the military values, as well, its LGB soldiers as a group and
recognizes that there are distinct assessment and treatment needs to achieve positive
outcomes. This could be set up as a
double blind study where the experimental group receives services from the
pilot group with special training and experience and the control group receives
services as they currently exist (but preferably for a similar time period) and
compare treatment outcomes and relapse rates at 3, 6 and 12 month intervals.

-Venue

The
Kaiserslautern/Ramstein complex is quite large (54,000 persons), and is often a
first stop after deployment to areas in the Middle East (where there is current
substantial American deployment). As a useful venue there would be availability
of a large contingent of soldiers returning from deployments in war zones who
may be stationed in the vicinity for some months prior to being redeployed or
in terms of completing service and returning to the U.S. The logistics of sampling the above group
before they relocate elsewhere is more cost effective. Also, it will likely
reduce memory bias in terms of asking questions about ATOD use immediately
after deployment which is subject to change the longer the length of time
between deployment and the soldier's next duty station or return home. Furthermore, treatment options in this area
of Germany are well staffed (from the author's personal experience) and can
offer a potentially larger range of services.
This would be ideal were the various hypotheses and the unique needs of
the returning deployed LGB soldier to be confirmed and it was determined that a
treatment program needed to be piloted, to assess outcomes and effectiveness,
to serve the specific needs of this group.

Conclusion

This article was
written to highlight that the problems and difficulties in providing effective
prevention and treatment services to a
service person returning from a stressful deployment is (like in many areas of
treatment in the civilian context), additionally dependent on characteristics
of the person and their background. Just
as men and women service-members have different experiences and specific
treatment needs (as do persons of different race and ethnicity), so too does
the LGB soldier. One of these needs is when that person does not have a solid
social network from which to draw support.
Also, the necessity of a confidential service that is staffed by persons
knowledgeable of the needs of this population, being able to demonstrate skill
in working with this group and holding non-judgmental attitudes are absolutely
essential to maximizing positive and meaningful measurable outcomes of success.

It is the
author's hope that the need to research, and confirm (or debunk) the extent of
these identified problems and hypotheses (which if true have implications for
confidentiality, screening, outreach and individualized treatment options), has
been sufficiently persuasive. The history
of DADT (only recently repealed) and the threat of confidentiality being
potentially compromised in medical settings factor into secrecy about oneself
and discourage linking in to necessary prevention and treatment settings. In the absence of this medical, community and
social support it is the author's strong belief that the LGB soldier, post
deployment, and in isolation, has nowhere else to turn except to the use and
misuse of alcohol and drugs which can result in the service person's life spiraling
out of control. The author is excited at
the prospect that this paper be published and the concerns thus brought to the
attention of or disseminated to the military community. It is hoped that the military commanders who
come across this paper in literature searches online or by other means will
contemplate action in support of this group which is an otherwise
under-researched albeit valuable segment of the military population in terms of
knowledge, skill and training. The
proposed argument for research and intervention targeting this specific
population can ultimately save the military from unnecessary expense, boost
morale and mental health, promote career development, and productivity and aid
in the retention of valuable personnel.

References

1. Hoge CW, Auchterlonie JL,
Milliken CS. Mental Health Problems, Use
of Mental Health Services, and Attrition from Military Service after Returning
from Deployment to Iraq or Afghanistan, JAMA. 2006; 295(9):1023-1032.

19. Frank, N. Gays and
Lesbians at War: Military Service in
Iraq and Afghanistan Under "Don't Ask, Don't Tell," Center for the Study of Sexual Minorities in the Military, 2004
September 15, UC Santa Barbara.

Author Biography:

Wes James Orr
obtained his M.S.W. degree in 1999. He went
on to obtain his L.M.S.W. from the State of Michigan which is the highest
credential for independent clinical practice for Clinical Social Workers. He acquired subsequent certifications from
the Academy of Certified Social Workers (ACSW) from the NASW and the Certified
Addictions Specialist (C.A.S.) from the American Academy of Health Care
Providers in the Addictive Disorders in 2002.
This was immediately prior to accepting a contractor post as a Social
Worker Addictions Counselor in the greater Ramstein/Kaiserslautern military
community in Germany for the U.S. In
this post (2002-5) he was credentialed by the Landstuhl Medical Flight and
worked supporting and treating military dependents and their families where
there were issues of ATOD abuse and addiction often existing with other co-occurring
disorders. At various times in his
career Wes has worked with individuals who were coming to terms with their
sexuality as LGB individuals who were experiencing both difficulties in linking
in to services and dealing with the prejudices of others and tending towards
self-isolation. Recent training includes
completion of the academic portion of a post-graduate diploma (3 years) in
Rational Emotive and Cognitive Behavioural Therapy from the Institute of
Cognitive Behavioural Therapy in Ireland.
Wes currently lives in Ireland working as a Senior Clinical Social
Worker for the Health Service Executive (Irish Health Service) practicing in an
outpatient mental health setting for the last 5 years. In this role he works with a combination of
persons having both acute and long-term mental health difficulties often
accompanied by addiction or substance abuse issues.